To Whom I May Concern® Facilitator Masterclass

Personal Information

Full Name*

PrefixFirst NameLast Name

Organization

Your Position

E-mail*

Phone Number*

Country Code (e.g. 1)Area CodePhone Number

Mobile Number

Country Code (e.g. 1)Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Please help us get to know you by telling us about your experiences

Do you currently or have you previously facilitated a support group for people living with dementia?

YesNoOther

Please tell us about your experience facilitating a support group or other group involving people living with dementia:

Do you plan on holding a To Whom I May Concern® performance in your community within 6 months of the training?

YesNo

Use this field to tell us anything you think would be helpful to us about your plans for To Whom I May Concern® in your community and/or your current work with people living with dementia.

Additional Trainees from the Same Organization

If you would like five or more people from your organization who would like to take the training together, please contact laura@towhomimayconcern.org to arrange for a private training session.

1st Additional Trainee

PrefixFirst NameLast Name

Position

E-mail

2nd Additional Trainee

First NameLast Name

Position

E-mail

3rd Additional Trainee

First NameLast Name

Position

E-mail

example@example.com

Payment

Please choose one of the following payment options:*

Invoice my organization (If you select this option, please do not select a registration fee below)Payment via PayPal (includes credit card option)

If you would like us to invoice your organization, below please enter the company name, address and to whom the invoice should be addressed AND their email address. Please indicate the number of registrations from your organization.

Please choose one of the following options. Payment is processed through PayPal.

Individual Registration Fee:$799.00

Group Registration Fee:$1,440.00

2 Trainees from the Same Organization. Includes 10% discount.

Group Registration Fee:$2,160.00

3 Trainees from the Same Organization. Includes 10% discount.

Group Registration Fee :$2,880.00

4 Trainees from the Same Organization. Includes 10% discount.

Enter coupon

Total $0.00